When You Must Apply for Medicare and When You Don't

You must explore for Medicare only if you are not automatically enrolled

Most people do not have to explore for Medicare. If you are a U.S. citizen or permanent resident who has worked and paid Medicare taxes for at least 10 years, you are automatically enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance) when you turn 65. Social Security handles this enrollment without any action on your part.

However, if you do not meet the work history requirement, or if you want Part B coverage to start before age 65 due to disability or end-stage renal disease, you will need to explore. You also must explore if you want prescription drug coverage (Part D) or a Medicare Advantage plan (Part C), because these are not automatic.

The key difference is between Part A and Part B, which are automatic for most people, and the optional coverages, which require you to take a step. Understanding which category you fall into saves you from missing important date that can cost you money in penalties.

Key Takeaways

• If you have worked and paid Medicare taxes for 10 years and are a U.S. citizen or permanent resident, you are automatically enrolled in Part A and Part B at age 65 with no process needed.
• You must explore for Medicare before age 65 if you are on Social Security Disability Insurance (SSDI) or have end-stage renal disease, because automatic enrollment does not happen until you turn 65.
• Part D (prescription drug coverage) and Part C (Medicare Advantage) always require you to choose and enroll, even if you are automatically enrolled in Part A and Part B.
• If you delay explore for Part B or Part D when you are first may be able to access, you may owe a penalty for each month you were not enrolled, even if you enroll later.
• You can explore through Social Security in person, by phone at 1-800-772-1213, or online at ssa.gov if you need to enroll before age 65 or add optional coverage.

Automatic enrollment at 65 and what it covers

When you turn 65, Social Security automatically enrolls you in Part A and Part B if you have been a U.S. citizen or permanent resident for at least five years and have paid Medicare taxes for at least 10 years (or are married to someone who has). You do not receive a form to sign or a button to click. Social Security uses its own records to determine your may be able to access and sends you a Medicare card in the mail about three months before your 65th birthday.

Part A covers hospital stays, skilled nursing facility care, hospice, and some home health services. Part B covers doctor visits, outpatient care, lab tests, and durable medical equipment. Both are funded through payroll taxes you paid during your working years, so there is no separate process process for people who meet the work requirement.

If you do not receive a Medicare card by the time you turn 65, contact Social Security to confirm your enrollment. Delays in the mail are rare, but they do happen, and you need proof of coverage to avoid gaps.

When you must explore before age 65

If you are under 65 and receive Social Security Disability Insurance (SSDI), you become may be able to access for Medicare automatically after you have been on SSDI for 24 months. You do not have to explore; Social Security enrolls you in Part A and Part B. However, if you want to enroll before the 24-month waiting period ends, you must explore through Social Security.

If you have end-stage renal disease (ESRD) and need dialysis or a kidney transplant, you can explore for Medicare regardless of age. Contact Social Security or your dialysis center, which often helps patients with the process. ESRD coverage begins the first day of the month in which you start dialysis or the month after you receive a kidney transplant, whichever comes first.

If you are not yet 65 and do not have SSDI or ESRD, you cannot enroll in Medicare, even if you explore. You will need to use the Affordable Care Act marketplace or your employer's plan until you reach 65.

explore for Part D and Part C requires a separate choice

Part D (prescription drug coverage) is not automatic, even if you are automatically enrolled in Part A and Part B. You must choose a Part D plan and enroll during your initial enrollment period, which is the seven months surrounding your 65th birthday (three months before, the month you turn 65, and three months after). If you do not enroll when you are first may be able to access, you pay a penalty for each month you go without coverage, even if you enroll later.

Part C (Medicare Advantage) is also optional and requires you to choose a plan. Medicare Advantage replaces Part A and Part B with a single plan offered by a private insurance company. You enroll in Part C during the same initial enrollment period as Part D, or during the annual open enrollment period from October 15 to December 7 each year.

You can enroll in Part D and Part C online at Medicare.gov, by phone at 1-800-MEDICARE, or in person at a Social Security office. The important date to enroll for the year is December 7, and coverage begins January 1.

Penalties for late enrollment in Part B and Part D

If you do not enroll in Part B when you are first may be able to access at 65, you pay a 10 percent penalty on your Part B premium for each year you delay. This penalty is permanent and stays on your bill for as long as you have Part B. The only exception is if you were covered by an employer's health plan while you were still working; in that case, you have eight months after your employment ends to enroll without penalty.

Part D has a similar penalty: if you do not enroll when you are first may be able to access, you pay 1 percent of the national average Part D premium for each month you were not enrolled. Like the Part B penalty, this penalty is permanent.

These penalties exist because Medicare assumes that people who delay enrollment are trying to avoid paying premiums while healthy, then enroll once they need prescriptions or medical care. The penalty is meant to discourage that behavior.

how the process works if you need to enroll before 65

To explore for Medicare before age 65, contact Social Security by phone at 1-800-772-1213, visit your local Social Security office, or go online to ssa.gov. You will need to provide proof of your condition (SSDI status or ESRD diagnosis) and your citizenship or permanent resident status.

If you have ESRD, your dialysis center or transplant team can often start the process for you. They have experience with Medicare enrollment for kidney patients and can answer questions specific to your situation.

Processing takes about two to four weeks. Once you are approved, you receive a Medicare card in the mail. You can use the temporary notice of coverage they send while you wait for the card to arrive.

What happens if you miss the enrollment important date

If you miss your initial enrollment period for Part B or Part D, you can still enroll during the general enrollment period from January 1 to March 31 each year. However, coverage does not begin until July 1, and you will owe the late enrollment penalty.

The only way to avoid the penalty is to prove that you had creditable coverage (coverage as good as Medicare) from another source during the time you were not enrolled. This might be an employer plan, COBRA, or a spouse's plan. You will need to provide documentation of that coverage to Social Security or Medicare.

If you miss the important date and do not have creditable coverage, enroll as soon as you can. The penalty grows each month you wait, so delaying further only makes it worse.

Frequently Asked Questions

Do I have to do anything to get Medicare at 65?

No. If you have worked and paid Medicare taxes for 10 years and are a U.S. citizen or permanent resident, Social Security automatically enrolls you in Part A and Part B. You will receive a Medicare card in the mail about three months before your 65th birthday. You do not need to fill out a form or call anyone.

What if I am still working at 65?

You are still automatically enrolled in Part A and Part B at 65, even if you are still working and covered by your employer's plan. You can delay Part B enrollment without penalty if you are covered by your employer's health plan and are still actively working. Once you retire or lose that coverage, you have eight months to enroll in Part B without penalty.

Can I refuse Medicare and keep my employer plan instead?

Yes, you can delay Part B enrollment if you have creditable coverage through your employer. However, you cannot delay Part A. If you do delay Part B, make sure to enroll within eight months of losing your employer coverage, or you will owe a penalty. Part A has no premium, so there is no penalty for having it.

What if I did not work 10 years but am married to someone who did?

If your spouse worked and paid Medicare taxes for 10 years, you may be may be able to access for Medicare Part A at 65 based on their work record. You will be automatically enrolled. Contact Social Security if you are unsure whether you may have access to based on a spouse's record.

Do I have to choose a Part D plan, or can I skip it?

You do not have to choose Part D, but if you do not enroll when you are first may be able to access and later decide you want it, you will owe a penalty for each month you were not enrolled. If you do not take prescription medications and do not think you will need them, you can skip Part D, but you cannot avoid the penalty if you change your mind later.